Sixty years ago, a battle against racial disparity in health care was fought in an unlikely place — the relative calm of heartland America — and an emergency department was at the center of it. Now, as new studies from emergency medicine demonstrate, that disparity-fighting effort may need to be waged again, though this time for far more elusive reasons.
The Midwestern town where the struggle arose those many decades ago was Kansas City, a metropolis known mostly at the time for its stockyards and for straddling two states that opposed each other in the Civil War. It also had what Carl Peterson, MD, termed “second-class” minority medicine, which seemed to unsettle only a very few who lived there.
Dr. Peterson, a Meharry Medical College graduate, returned to his urban home along the Kansas-Missouri border after he had served in World War II. He began his practice with a very wrong post-war assumption: That racial inequity in medicine was dying.
“Things had not improved one iota,” Dr. Peterson said of that time when he resumed his medical career at General Hospital No. 2, which served the city's black population. “Everything was secondhand.”
Even fresh supplies destined for his hospital often were diverted to its all-white counterpart, Hospital No. 1. “I took this as long as I could and longer than I should,” he said during an interview at the time. (From Shamans to Specialists: A History of Medicine in Jackson County, Missouri. Kansas City, MO: Jackson County Medical Society; 1981.)
Then, in a stunning act that would overcome the resistance of colleagues who considered him a sell-out and countering the discrimination of white doctors who strongly favored segregation, Dr. Peterson did the unthinkable. He called for a strike that he pledged would last until white physician specialists helped train the hospital's black doctors in their various specialties.
Only the emergency department was to remain open at General Hospital No. 2 in January 1947, and it became the focus of a swarming news media. Soon, nine white doctors stepped forward to be department supervisors. Photos from the era show these physicians, old and new, working side by side as they ushered in a very different meaning for the term medical team.
Newspaper accounts fail to reveal whether it was these pictures that turned the tide, the plain-spoken appeal of Dr. Peterson himself, or whether the ED helped to burnish an unforgettable public image of minority patients in need. By 1949, having forged interracial specialty training, the city was the site of the nation's first multispecialty group practice founded by African American physicians. By 1951, the county medical society had removed its stipulation to admit only white doctors. Two decades later, that same county medical society elected Dr. Peterson its first African American president, an incident recounted in detail by the very organization that had once excluded him. (Jackson County Medical Society Archives, 1972.)
Such triumphs, played out similarly across the United States, didn't end health care disparity, as scores of medical publications currently show. Instances of blatant racism, however, gradually became much more atypical. Leaf through the pages of past medical graduates of the Kansas University School of Medicine at Kansas City, for example, and those faces change as years progress, from predominantly Caucasian men to a diverse group that would make Dr. Peterson proud.
So why do the results of some recent investigations show a seeming reversal, that whites are getting better treatment in the ED? Those findings are perplexing to some emergency physicians, particularly to emergency physician Michael Nottidge, MD, MPH, the lead author on one of those studies from Johns Hopkins University. It clearly indicates disparity related to race in several Baltimore EDs. Blacks and Hispanics had a 10 percent lower chance of being triaged within the appropriate 15-minute window compared with whites in the same hospital. (Acad Emerg Med 2009;16Suppl 1:273.)
Precisely why such differential treatment occurs remains a mystery. “Most health professionals really are caring,” Dr. Nottidge said. Whatever bias may account for these differences “very likely exists in a subconscious, unintentional way,” he said.
But how? “There is something that we are doing that is not entirely equal,” he affirmed. But is it the result of behavior patterns on the part of health care staff? Or of cultural norms that influence the way the system responds? Or does it result from the way patients present themselves in the ED? Or from the type of provider these patients face during the initial encounters?
When researchers from the University of Florida in Gainesville examined why African American men have an age-adjusted incidence of oral cancer more than 20 percent higher than that of white men, they found it likely that the related — and disproportionate — death rate was due to multiple factors, among them low public awareness of risk factors and distrust and misinformation of screening. (Am J Health Behav 2008;32:684.)
Another possibility is that minority patients do not advocate for themselves as effectively as their Caucasian counterparts, and as a result, are more likely to experience treatment delays.
“The social and cultural variables seem endless,” Dr. Nottidge observed. Although the data Dr. Nottidge and his colleagues analyzed were drawn from comparisons among patient groups at the same hospital, team characteristics were unable to be assessed, he pointed out. “Some teams have a predilection for night-shift work; others work on a schedule that is more of a mixture. These teams, quite literally, may be different in personality,” he said.
Two public health investigators, one at the University of Illinois at Chicago, the other at the University of North Carolina at Charlotte, did in-depth interviews with a dozen middle-aged or older African American women with heart disease over a two-year period to determine how cultural factors might affect their health care. They found that immediate family members can positively or negatively influence lifestyle changes and self-care among the women. (Am J Health Promot 2008; 22:342.). “I think sociologic-socioeconomic factors probably weigh heavily into tolerance for waiting [and] whether to go to the ED in the first place,” said Chet Schrader, MD, the chief resident in emergency medicine at Washington University and Barnes-Jewish Hospital-Saint Louis Children's Hospital. “I have seen our inner-city population tolerate long wait times, and I have seen individuals at a suburban hospitals upset that they had to wait at all.”
Like Dr. Nottidge, Dr. Schrader is the lead author on a series of studies that show disparities related to race. He and colleagues have shown African American patients have longer mean wait times than Caucasians with nearly the same triage acuity scores. (Acad Emerg Med 2009;16 Suppl 1:262.)
“I think it's important to note that, while we do see a difference in how long it takes an African-American and Caucasian to get back to emergency department treatment rooms, it's been difficult to discern why exactly it's happening,” Dr. Schrader said. “Our study was an attempt first to show whether or not disparities were occurring, and then, if it was happening, to set out to explain why.” So far, they have not been able to do so.
“In our study, we tried to control for as many variables as possible, but we readily acknowledge there have been limitations,” Dr. Schrader explained. “Ideally, we would look closer at the complete picture presenting to the triage desk, including things like vital signs and ill appearance, to be able to determine why disparities exist,” he added. “While our study still shows that there continues to be a difference in wait times, we know we haven't been able to show the whole picture.”
A 2003 survey showed that information crucial for good decision-making is not given in one of every seven primary care office visits. (Principles of Ambulatory Medicine. Philadelphia: Lippincott Williams & Wilkins; 2007.) Could such allegedly poor doctor-patient exchanges account for the same kind of thing occurring in EDs? Perhaps, if an investigation of a British ED is applicable. Interview data from physicians and patients with chest pain in a London ED showed heavy reliance on clinical history. Much of the time, it came directly from patients, and there were barriers to understanding, particularly by physicians who often unwittingly injected their own perceptions into the descriptions. (Ann Emerg Med 2006; 48:77.)
Perhaps differences in interactions with the triage staff in the ED account for racial disparity, Dr. Schrader said. “In fact, one hypothesis I had in the beginning of our research was the possibility of interactions with the triage staff. Short of placing an investigator at the triage desk to observe every interaction, we thought it difficult to prove,” he said.
When the United States was a much younger country, such presumptions were part of the medical literature, and were considered quite practical. In the 19th century, for instance, doctors assumed that certain patient groups were quite different from others, and should be treated as such. These assumptions were not considered controversial, and weren't based on race either. One example was that “farm folk” were seen as sturdier and stronger. In contrast, residents of urban areas were routinely judged as more frail.
For physicians who treated city and country dwellers, the latter patients were presumed to be better able to handle treatment delays. Though in retrospect this seems prejudicial, it was considered common sense and good medical practice at the time. “A farmer with acute rheumatism might easily lose 60 to 70 ounces of blood in treatment, but a sedentary resident of the city could hardly tolerate the loss of half that quantity,” posits a very matter-of-fact record of early colonial medicine. (A History of Medicine. New York: Taylor & Francis Group; 2005.)
Three years ago, Australian researchers looked at much the same assumption to see if it meant differences in outcome for patients. They wanted to know how residents from the outback stacked up against those from a major city in terms of cancer treatment. Were these patients tougher? The pilot study showed that rural residents had delays in diagnosis and therapy, but these delays weren't due to greater tolerance for pain or a stoic dismissal of early symptoms. Instead, the results indicated that poorer outcomes had occurred because these patients possessed resigned, fatalistic attitudes that may have kept them from seeking medical care earlier. (Rural Remote Health 2006;6:563.)
So the Australian investigators asked a simple follow-up question: What can be done to improve the situation? As one partial solution, they suggest establishing the “rurality” of patients, a term aimed at helping to identify people who feel they need to accept any bad luck life throws their way. After all, these fatalists aren't apt to be the most compliant of patients, they pointed out.
Dr. Schrader and Dr. Nottidge have asked themselves the same question: What can be done to improve the situation? The answer they get calls for more research. “What we can say is that this serves as a wake-up call, showing that some self-scrutiny is needed,” Dr. Nottidge said.
And it is exactly the same conclusion reached by Dr. Peterson more than a half century ago when he published a commentary on the improvements needed at General Hospital No. 2. Ten years after the strike threat that led to integration at his hospital, the facility merged with Hospital No. 1, ending segregation. This fall, not far from where General Hospital No. 2 once stood, an inner city clinic, the Hope Family Care Center, will open its doors to the largely African American community around it. “Our residents primarily get their care from EDs,” noted Matt Nagel, the operations director for the center, “but once it opens, that won't be as much the case.”